Unhealthy Advertisements on Corner Storefronts and Smoke ...A semi-structured focus group questioning guide was developed by the evaluation team and staff from the Stanislaus County

Stanislaus County Health Services Agency

Unhealthy Advertisements on Corner Storefronts and Smoke-free Living in Multiunit Housing Focus Group Findings, June 2013

TABLE OF CONTENTS

BACKGROUND 1

DESCRIPTION OF THE FOCUS GROUPS 1

Unhealthy Advertisement on Corner Storefronts Focus Groups 1 Research Questions for Unhealthy Advertisement on Corner Storefronts 2 Smoke-free Living in Multiunit Housing Focus Groups 2 Research Questions for Smoke-free Living in Multiunit Housing 3

OVERVIEW OF FINDINGS 3

FINDINGS UNHEALTHY ADVERTISEMENT ON CORNER STOREFRONTS – YOUTH PERCEPTIONS 3

General Impressions of Storefront Advertisements 3 Effects of Storefront Advertisement on the Community 4 Connection Between Storefront Advertisements to Health 5 Perceptions about Healthy Advertisements 6 Support for the Lee Law 6 Capacity and Strategies to Promote Change 7

FINDINGS UNHEALTHY ADVERTISEMENT ON CORNER STOREFRONTS – ADULT PERCEPTIONS 7 General Impressions of Storefront Advertisements 7 Effects of Storefront Advertisement on the Community 8 Connection Between Storefront Advertisements to Health 8 Perceptions about Healthy Advertisements 8 Support for the Lee Law 9 Capacity and Strategies to Promote Change 9

SUMMARY FROM HEALTHY STOREFRONT ADVERTISEMENT FOCUS GROUPS 9

FINDINGS SMOKE-FREE MULTIUNIT HOUSING – NON SMOKERS’ PERCEPTIONS 11

Perceptions of Secondhand and Thirdhand Smoke on Health and Level of Concern 11 Experience in Asking People to Stop Smoking 11 Perceptions on Smoking Rules and Regulations for Multiunit Housing 12 Facilitators and Barriers in Establishing Smoke-free Housing 13 Strategies for Engaging Multi-Unit Housing Residents to Promote Smoke-free Environments 13

FINDINGS FROM SMOKE-FREE MULTIUNIT HOUSING – CURRENT SMOKERS’ PERCEPTIONS 13 Perceptions of Secondhand and Thirdhand Smoke on Health and Level of Concern 14 Experience in Being Asked Not to Smoke 14 Perceptions on Smoking Rules and Regulations for Multiunit Housing 14 Facilitators and Barriers in Establishing Smoke-free Housing 15 Strategies for Engaging Multi-Unit Housing Residents to Promote Smoke-free Environments 16

SUMMARY OF THE SMOKE-FREE MULTIUNIT HOUSING FOCUS GROUPS 16

TABLES

Table 1: Demographic Description of Storefront Advertisement Focus Group Participants 2 Table 2: Demographic Description of Multiunit Housing Focus Group Participants 3

1 Sarah Samuels Center for Public Health Research & Evaluation

STANISLAUS COMMUNITY TRANSFORMATION GRANT Unhealthy Advertisement on Corner Storefronts and Smoke-free Living in Multiunit Housing

Focus Group Report

BACKGROUND

As a result of the growing evidence for an environmental approach to food and physical activity, there has been a shift away from individually-oriented health education and behavior change strategies to improving environments in which people live, work, learn and play.1,2 The Centers for Disease Control and Prevention, through the Community Transformation Grants (CTG),3 supports state and local government agencies, tribes and territories, nonprofit organizations, and communities across the country to design and implement community-level programs that prevent chronic diseases such as cancer, diabetes, and heart disease. As a CTG capacity building grantee, the Stanislaus County Health Services Agency is conducting a community-engaged health assessment to plan their intervention strategies.

As part of this work, The Sarah Samuels Center for Public Health Research & Evaluation (Samuels Center),4 formerly Samuels & Associates, conducted two sets of focus groups to assess: 1) Community residents’ perceptions around unhealthy food and tobacco advertisement on local (“corner”) storefronts and 2) Secondhand and thirdhand smoke in multiunit housing in Stanislaus County. Findings are anticipated to inform strategies to reduce exposure to unhealthy storefront advertisement and reduce exposure to secondhand and thirdhand smoke for residents living in multiunit housing. The focus groups were conducted in the fall of 2012 and spring 2013. The research protocol and tools were approved for the protection of human subjects by Ethical & Independent Review Services.

DESCRIPTION OF THE FOCUS GROUPS Unhealthy Advertisement on Corner Storefronts Focus Groups Four focus groups were conducted to understand perceptions and level of concern from youth and community residents regarding the exposure to tobacco and unhealthy food and beverage advertisement on local storefronts and its influence on health. Two focus groups were conducted with youth (age ranged between 14 and 18); one group with all male youth and one with all female youth. Youth were recruited through a community organization called Project YES (Youth Employment Services), located in Ceres, California, which is where the focus groups were conducted. Youth under the age of 18 and their parents signed assent forms, and youth 18 years of age and older signed consent forms. In addition to the two youth groups, two adult focus groups were also conducted using the same focus group questions. One adult group was conducted in English, and the other group was conducted in Spanish with women. See Table 1 for focus group type, number of participants, and language.

1 Economos CD, Hyatt RR, Goldberg JP, Must A, Naumova EN, Collins JJ, et al. A community intervention reduces BMI z-score in

children: Shape Up Somerville first year results. Obesity (Silver Spring) 2007;15(5):1325-36. 2 French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health 2001;22:309-

35. 3 http://www.cdc.gov/communitytransformation

4 http://samuelscenter.com


Table 1: Demographic Description of Storefront Advertisement Focus Group Participants

Description of Focus Group N Language Youth – Male 9 English Youth – Female 9 English Adult – Female 12 Spanish Adult – Mixed gender 9 English

Research Questions for Unhealthy Advertisement on Corner Storefronts A semi-structured focus group questioning guide was developed by the evaluation team and staff from the Stanislaus County Health Services Agency to address the following research questions: 1) What are the perceptions of community residents/youth about the influence of tobacco products

and unhealthy food and beverage advertisement on storefronts and its influence on health and their opinions on the extent of the problem?

2) What are community residents’/youth opinions regarding the influence of advertisements on corner storefronts on purchasing behavior and overall health?

3) What is the level of support or opposition from community residents/youth in supporting and enforcing the Lee Law5 and support for a greater ratio of healthy vs. unhealthy advertisements on storefront windows and doors?

4) What resources are needed to support and build community residents’/youth capacity to effectively support healthy advertisement on local storefronts?

5) What are effective and culturally appropriate strategies for engaging community residents/youth to promote for healthier advertisements on storefronts?

Findings are anticipated to understand the level of support for this intervention and to inform the development of strategies to reduce unhealthy tobacco product and unhealthy food and beverage advertisement in storefronts in an effort to create a healthy environment. Smoke-free Living in Multiunit Housing Focus Groups Two focus groups and interviews with 3 community residents were conducted to understand multiunit housing residents’ perceptions and level of concern regarding the exposure to secondhand and thirdhand smoke and its influence on health. All participants signed consent forms and were those who currently lived in multiunit housing and were either current smokers or non-smokers. See Table 2 for focus group type, number of participants, and language.

5The Lee Law in California allows no more than 33% of a storefront’s windows/doors to be covered by any type of signage or

advertising as well as support for having a greater ratio of healthy vs. unhealthy advertisements on storefronts, particularly stores that are in close proximity to schools.


Table 2: Demographic Description of Multiunit Housing Focus Group Participants

Description of Focus Group N Language Age Group Smokers 4 English Adult Smokers 3* Spanish Adult Non-Smokers 13 Spanish Adult Non-Smokers 14 English Adult * Since 3 participants arrived at the session at different times which made a focus group session not feasible, the participants were interviewed individually for their opinions and their responses were incorporated into the overall findings.

Research Questions for Smoke-free Living in Multiunit Housing A semi-structured focus group questioning guide was developed by the evaluation team and staff from the Stanislaus County Health Services Agency to address the following research questions: 1) What are the perceptions of multiunit housing residents’ about the influence of secondhand and

thirdhand smoke on health and their opinions on the extent of the problem? 2) What do multiunit housing residents see as their role in creating smoke-free living environments? 3) What are the factors that facilitate or prohibit multiunit housing residents’ efforts in working

towards establishing a smoke-free environment? 4) What resources are needed to support and build multiunit housing residents’ capacity to effectively

promote smoke-free multiunit housing? 5) What are effective and culturally appropriate strategies for engaging multiunit housing residents to

support smoke-free environments? The questions for the focus groups and interviews were tailored to the specific groups, for example, questions were made applicable to the current smoker or non-smoker. Findings are anticipated to inform the development of smoke-free multiunit housing policies and strategies to create a healthy smoke-free environment. OVERVIEW OF FINDINGS In this section, findings are first reported for the Unhealthy Advertisement on Corner Storefronts, first from the youth perspective, then from adult community residents’ perspective. Findings will then be described for the Smoke-free Living in Multiunit Housing Focus Groups, first from the non-smokers perspectives, then from the smokers. Summary of findings are highlighted for each of the 2 sets of focus groups. FINDINGS UNHEALTHY ADVERTISEMENT ON CORNER STOREFRONTS – YOUTH PERCEPTIONS Two focus groups were conducted with youth; one group with all male youth and one with all female youth. General Impressions of Storefront Advertisements Both male and female youth participants were keenly aware of storefront advertisements on corner stores and markets in their communities. Both groups named similar types of products they see, with tobacco and snack foods such as chips and sodas among the first to be identified. Other product advertisements they typically see includes alcohol, lottery tickets, discounts, milk, and ice cream.


When asked for their opinions about these storefront ads, the female youth reported that the ads “make you want it,” and said that product discounts and special offers caught their attention and influenced where they made purchases. The male youth talked about the unhealthfulness of advertised products:

“They’re selling a product that’s giving you cancer” “I don’t agree with how they advertise.”

Both groups recognized tactics that advertisers use to influence consumers to buy their products, such as sex appeal, celebrities, athletes, and health claims on large, colorful, and attractive ads to make the products more enticing. Both groups also reported that people in the ads are depicted as always having fun and being active in nice environments, creating the illusion that the products will have a positive influence on people who consume them. One male youth reported that the ads appeal to children who often ask their parents for unhealthy or adult-focused items. A female participant said that alcohol and tobacco ads should show what those products actually do to people. The male youth also commented on the influence of ads, for example, one participant reported that the placement of ads outside the stores was influential because they prime people to want those items before they enter the store and influence shoppers who didn’t intend to purchase the item:

“They’re essentially trying to shove that product into your mind so you start thinking about it later,

and you’re like, “You know. I’ve got to try it.”

A male youth commented that “you don’t want what you never knew existed,” implying that ads make a person aware of the product, and that ads are “why most of us are unhealthy.” Both groups discussed the draw of discounts and/or promotions, specifically talking about the influence of the “two for one” or “two for $3” special promotions. Female youth reported that the ads were especially effective for new products or new flavors of existing products since people always want to try something new. Overall, both groups reported that storefront ads are effective in influencing purchases. A female youth reported that advertisers should tell the truth about their products:

“I think if advertisements wanted to change people’s opinions, like if someone wanted to say, “alcohol is bad”, then put a fat guy on there with a beer-belly. Or with cigarettes, put someone that

has cancer or someone who has to talk out this, with a pack of cigarettes in their hand…Stuff like that. Make it look worse because it really is worse.”

Effects of Storefront Advertisement on the Community When both groups were asked about the influence of storefront advertisements on their communities, the male and female participants had different responses. The majority of the youth in the male group reported that storefront ads are a big problem in their communities, while the female youth did not think that the ads were a problem. The male youth focused on the ads’ potential effect on children, saying that it was a problem that children see ads that are aimed at adults, and that ads make adult products such as tobacco and alcohol seem “cool.” A male participant said that thinking adult products are cool can plant a desire for these products in children at a very young age:

“They put the age amount on products, so you live growing up with it, learning about it, knowing

about it, and then when you’re 18, you just buy everything you see.”


In addition to children, male participants reported that men were targeted in storefront ads, with most beer ads using messages that incorporate sports, watching sports on television, and relaxing. They also reported that teens are especially susceptible to ads as well as people who are “ignorant,” or might not know the truth behind ads. The overall consensus was that everybody is targeted by storefront ads, and there are too many of them. At least one participant in both the male and female groups reported that seeing cigarette ads as children influenced their desire to try cigarettes and their subsequent addiction to cigarettes. A male participant told his story about tobacco:

“I ended up smoking mainly because every time I went down to the store, I always saw on the wall,

‘USA Gold’ - it had the picture of the cowgirl on the front, this golden retriever, and it was the true

American cigarette and all that, and it got stuck in my head. So I thought, ‘You know what? I’m going

to try it.’”

The female youth reported that their peers are more influential than ads and that a person’s decision to smoke is not influenced by ads:

“I think it really doesn’t matter how you advertise stuff or whatever, how the ad looks. It’s basically based on the person. If you smoke and you see this advertisement about the cigarettes, that’s all on you or if you see this about chips, it’s all on you. It all depends on the person. It really has nothing do

with the ads.” A male youth reported that tobacco ads made it very difficult for him to quit smoking because he was reminded of cigarettes every time he drove past a corner store in his community. Despite the female group’s insistence that storefront tobacco ads are not influential, participants in both groups reported that if there were no ads, there would be no smokers. One participant suggested limiting tobacco ads to the inside of stores. Both groups also said that tobacco ads might have a bigger influence on current smokers than those that do not already smoke because most tobacco ads are for sales or promotions which affect current smokers rather than non-smokers:

“It doesn’t make people smoke, but it makes them smoke more often if they already are.”

Connection Between Storefront Advertisements to Health Participants were asked for their opinion about the connection between storefront ads and diabetes, obesity, and hypertension. One participant reported that his mother, who suffers from diet-related health problems, consumes the unhealthy advertised items because of the number of ads she has seen over her lifetime. The majority of the female youth did not blame the ads or the food and beverage companies for health problems:

“I don’t think it’s the company’s fault; if you’re going to keep drinking sodas, it’s your own fault. Companies shouldn’t be held responsible for that.”

Another participant said that parents should control what their children eat. Although the majority of participants reported that ads do not contribute to obesity and other related diseases, a few youth spoke about environmental influences on health-related behavior.


Perceptions about Healthy Advertisements Youth were asked for their opinion whether advertisements of healthy foods and drinks, such as fruit and water, on the storefronts of their corner markets would make a difference. Male participants reported that ads for healthy products would have a positive impact:

“They wouldn’t be so overwhelmed by junk food, and you wouldn’t be seeing it so much. You might

be even less tempted to buy it.”

Another youth also talked about the positive effect of reducing unhealthy ads:

“I think if advertisements were reduced for unhealthy foods, people might make the right choice a little more often.”

Two participants reported that ads for water would make people drink more water. The female youth reported that healthy food and beverages ads already exist. A female participant said that ads for healthier food and beverages would increase the healthy items people bought: If there were more healthy ads, I think that it would be more popular, the healthier stuff rather than junk food. Just because it’s around; it’s out there more noticeable, and people would maybe see it more and

be like, “Okay, well that’s good.” because it’s everywhere.” Several female participants talked about the need for stores to advertise their specific products:

“If you go to the liquor store, I think it’s supposed to be cigarettes and liquor on those

advertisements. I think that when you go to the store for clothes, there are clothes on the window. You go to the grocery store, and they got the good, healthy foods and you see celery and salads.”

Support for the Lee Law Participants were asked for their opinion about the Lee Law which limits ads on storefront windows or doors to cover one-third of the front of a store. Participants in both groups reported that they typically see much more than one-third of corner store windows covered with ads. Opinions about the utility of the Lee Law were varied in the female and male groups. Overall, both groups felt the law was “pointless” without enforcement. Several participants disagreed with the law, saying it was unfair to the storeowners because the ads help to attract business so they can earn a living. Another participant reported that storefront window ads don’t matter and even if there were no ads, there are still many ads for unhealthy items on the inside of the stores. In a discussion about protecting children from inappropriate ads, a few of the female youth reported that limiting outdoor window coverage would limit children’s exposure to products such as alcohol and tobacco, which may decrease their desire for those products:

“I think that there shouldn’t be cigarettes and alcohol because what if it’s an elementary school and there’s little kids right there? Those should be kept inside on the walls and not the windows.”

One female youth said that corner or liquor stores are for adults, and that children shouldn’t be there in the first place.


In regards to overall support for the Lee Law, about half of the male youth and a third of the female youth said that they would vote for it and reemphasized the need for enforcement. One participant reported that fewer ads might decrease the temptation to buy less healthy items. Safety was also reported as a good reason to limit window coverage. Capacity and Strategies to Promote Change Participants were asked about ways in which they could strategize to have healthier ads on corner stores. Both groups reported the need to speak directly to store owners about the ads; however, both groups also predicted that store owners would resist changing ads or may be worried about losing income:

“It all comes back to how much they’re getting paid.”

The male youth discussed the need for change at the industry level rather than the corner store level. They suggested offering a monetary incentive to stores to reduce the number of unhealthy storefront ads. The key stakeholders they felt should be involved include school district administrators, local and state level elected officials, business leaders, and local organizations. Both male and female youth suggested petitions as a way to gain support for reducing storefront advertising:

“If you give people a chance to express their interests and emotions towards it and see how bad things in the stores have affected the community, it may inspire someone to say, “Hey let’s put a

stop to it.” FINDINGS UNHEALTHY ADVERTISEMENT ON CORNER STOREFRONTS – ADULT PERCEPTIONS In addition to the two youth groups, two adult focus groups were also conducted using the same focus group questions. One adult group (mixed gender) was conducted in English, and the other group was conducted in Spanish with all women participants. General Impressions of Storefront Advertisements When asked about the types of advertisements they see on the storefronts of their neighborhood corner stores, the Spanish-language women reported that there were too many ads, with a particular concern about the negative impact ads have on people, especially children:

“I am in contact with teens and I ask them what they want to be when they’re 18 or 21 and they tell

me they want to be an adult so they can drink. They’re thinking of being adults not for voting, not for

having a job or graduating, but for drinking.”

They cited ads for alcohol, tobacco, energy drinks, chips, and soda as being the most prevalent ads they see. Participants reported that the ads were usually very large and colorful, making them hard to ignore. Both groups reported that the promotional ads with sales or deals draw a lot of attention and said it would be good if “people didn’t have to look at the ads all the time.”


Effects of Storefront Advertisement on the Community The English-language group expressed concern about the corner stores in general, particularly the high number of corner stores in low-income communities as compared to higher income communities. They described the corner stores as places where youth tend to congregate and get involved in drugs and alcohol, but did not specifically cite ads as causing this problem. Participants talked about a few corner stores in their community that have murals on their walls that depict families and positive images, which they felt were misleading because the stores only carry unhealthy items and are not family-friendly. A participant said that youth already know where to purchase unhealthy items, so ads do not really affect them. They reported the issue of pricing as a problem, stating that unhealthy items like cookies or sodas were sold at very low prices compared to bottled water or produce. The idea of getting children “hooked” on unhealthy items at a young age was described as a concern:

“I didn’t think my child was paying attention to those ads, but for Christmas we celebrate Los Reyes Santos instead of Santa Claus, and he saw a camel on the cigarette ad and thought it was the Reyes

Santos’ camel instead. He’s just 5 years old.” A number of Spanish-language participants reported that the ads catch their children’s attention who then begs for the items, creating more difficulty for parents during shopping trips. Several Spanish-language participants were in agreement that many of the ads are directly targeted to the Latino community. They reported that the ads are usually for adult items (tobacco, alcohol, and energy drinks) and these ads encourage the desire and consumption of those items well before the children can buy the products. Another participant reported that the ads are most influential on middle- and high-school-aged youth who have some disposable income and are not as closely supervised as younger children. Connection Between Storefront Advertisements to Health Participants were asked for their opinion about the connection between storefront ads and diabetes, obesity, and hypertension. The Spanish-language participants drew a direct connection between poor health and the items that are advertised on corner stores. One participant reported that the unhealthy advertisements “ruin our bodies little by little.” Participants reported that the health consequences of the advertised items, such as cigarettes, are never included. Perceptions about Healthy Advertisements Participants were asked for their opinion whether advertisements of healthy foods and drinks, such as fruit and water, on the storefronts of their corner markets would make a difference. Most participants in both groups felt that healthy advertisements would create a positive change and thought healthy ads would have a positive effect:

“If the bombardment of ads were the opposite, the kids would automatically want the healthy foods. And I am sure that the kids would change and we wouldn’t be spending so much tax money on

diseases.” Participants also discussed several challenges with corner stores. For example, an English-language participant reported that ads for healthier foods would not have an effect unless there was a way to get


those healthy items into their corner stores. They also reported that corner stores charge higher prices for the small selection of produce that is available.

A Spanish-language participant reported that healthy ads would likely not change her habits because she knows about healthy foods but still buys junk food. Support for the Lee Law Participants were asked for their opinion about the Lee Law which limits ads on storefront windows or doors to cover one-third of the front of a store. The Spanish-language participants reported that some store windows are heavily covered with ads that they serve as curtains or decorations. They were in favor of limiting the size of the ads and suggested they be limited to the area inside the store where the item is being sold. Participants in the English-language group reported that policy enforcement would be more effective than community members talking to store owners on their own. Capacity and Strategies to Promote Change Participants were asked about the ways in which they would strategize to promote healthier ads on corner stores. Spanish-language participants reported that they are more aware of the Lee Law and would report stores that are not in compliance. The English-language group participants suggested using the public school system as a model for creating positive change around nutrition. A participant suggested collaborating with non-profit agencies to focus on corner stores. Both groups reported organizing demonstrations or protests as possible ways to bring attention to this issue. The English-language group reported that the important issue for stores is making a profit and if they can make a profit from fruits and vegetables, they will sell them. A Spanish-language participant reported that the food companies are the most important entities to confront about their advertising strategies as opposed to the corner stores. The Spanish-language group suggested speaking with city hall, the chamber of commerce, schools, and government assistance programs like WIC or EBT to get the conversation started and to build support. They reported that women would have to be the leaders of this movement since they are usually the main purchasers of food for families. Another suggestion was to involve youth, who are required to earn service hours, to start a petition in the community or to have them talk directly to store owners about the ads. SUMMARY FROM HEALTHY STOREFRONT ADVERTISEMENT FOCUS GROUPS Both youth and adult participants in the focus groups were keenly aware of the presence of corner store advertising and marketing tactics and all groups readily named product advertisements on corner stores. The majority of the male youth and Spanish-language adults expressed concern about the presence of unhealthy store ads, while the female youth reported less concern for the storefront ads. The adult English-language participants reported more concern about the presence of corner stores and the presence of negative youth behavior, rather than the ads on the stores. All four groups had at least a few participants who supported the need to increase healthy store ads and decreasing unhealthy store ads. The male youth and adult Spanish-language groups both reported that the ads affect the community’s health negatively. Overall, members of all groups voiced concern about the health of children and youth and reported that ads increased desire for unhealthy items at a very


young age. In addition, promotional ads with sales or special price discounts were described as influential in the purchase of unhealthy items. Support for the Lee Law was mixed. There was consistency in most groups that the law was not being enforced, with comments from all groups that most corner stores have more than one-third of their storefronts covered in ads. The participants who reported that ads had a negative health effect on the community were in support of the law, and wanted information on reporting non-compliant stores. Most of the participants in the youth and Spanish-language adult group believed that removing unhealthy ads could decrease the purchase of those items. Participants also reported concern for the storeowner, who could be impacted negatively if they were unable to advertise both unhealthy and healthy items. Participants who were in favor of increasing healthy ads described multiple ways to increase community support. They suggest starting with schools, which have successfully made changes to improve school offerings of food and beverages. Some participants also reported approaching store managers, but also stressed that the change would have to come from a policy in order to make all stores comply. Groups also discussed working through existing community groups to encourage stores to reduce unhealthy advertisements on corner storefronts.


FINDINGS SMOKE-FREE MULTIUNIT HOUSING – NON SMOKERS’ PERCEPTIONS Two focus groups and interviews with 3 community residents were conducted to understand multiunit housing residents’ perceptions and level of concern regarding the exposure to secondhand and thirdhand smoke and its influence on health. Perceptions of Secondhand and Thirdhand Smoke on Health and Level of Concern Participants were asked for their opinion about secondhand and thirdhand smoke and its effect on health. Participants reported that they did not want to be exposed to secondhand smoke, and were especially concerned for children. Several participants reported that when someone smokes in their presence, they feel disrespected, and that smokers can have a sense of entitlement. Participants said that secondhand smoke affects the non-smoker more than it affects the smoker. Another participant described smoking was a fire hazard. Regarding thirdhand smoke, overall, the English-language participants seemed more aware of thirdhand smoke than the Spanish-language participants:

“I didn’t know about thirdhand smoke. I lived three years in a trailer. When we started living there my kid had a cough daily. I didn’t know that the people that used to live there smoked a lot. I thought

it was because the trailer was really old and the windows were broken. I thought it was because of the humidity that the water got inside. But it was the smoke because it did smell of smoke a lot when

we started living there. He had a daily cough. As soon as we left he stopped coughing.” When participants were asked about the ways secondhand or thirdhand smoke might affect people, both groups talked about the potential health problems such as asthma, lung cancer, COPD, emphysema and bronchitis. They suggested that smoke affects children, babies’ brain development, and that their clothes “reeked” when exposed to smoke. When participants were asked for their opinion about being exposed to secondhand or thirdhand smoke, they reported frustration, anger, helplessness, and stress. One participant reported that it bothers him because he has asthma. The Spanish-language participants described the ways secondhand or thirdhand smoke affects them, such as getting headaches, dizziness, dry mouth, desperation, and having a sense of drowning. Most participants were in agreement that secondhand smoke was a significant problem, particularly for children, as the Spanish-language participants emphasized that children don’t have a choice and cannot defend themselves. A participant said that secondhand smoke was a bigger problem than smoking. There was also agreement among a number of participants that “the problem is bigger than drugs.” Experience in Asking People to Stop Smoking When participants were asked about their experiences in asking others not to smoke, the majority of the English-language participants reported not having any problem asking smokers not to smoke around them or their children. One participant said that she plans to ask her neighbor not to smoke. On the contrary, the Spanish-language participants reported being afraid to ask, for example, one participant said:

“My father also smoked. I never asked him, because he was my father – just because of that.”


Another participant reported that she sends her kids to ask their neighbor not to smoke because she felt he would respond more positively to her kids’ request than to hers. One participant reported a fear of being questioned about smokers’ rights:

“I haven’t asked the neighbor near my apartment because I don’t know if he’s going to ask me, “Where does it say I can’t smoke?” or, “Where are the rules I have to follow?” or, “I signed a contract

and it doesn’t say anything there that I don’t have to smoke.” That’s why I haven’t done it. I don’t know the rules.”

When asking people to stop smoking, a few participants reported that smokers can get frustrated, upset, and sometimes do not listen. Some participants reported feeling isolated when smokers would no longer visit them, after being asked not to smoke. Perceptions on Smoking Rules and Regulations for Multiunit Housing The participants were asked for their opinion about regulations for apartment complexes that only allowed smoking in the apartments or specific smoking areas or rules that don’t allow smoking in apartments, patios, or anywhere on the grounds. While most participants supported having smoking rules for their apartment complex, they had different opinions about the type of rule they would like to see. A few of the participants expressed the importance of enforcement. The Spanish-language participants made the following comments about smoking rules in apartment complexes:

“If you tell them they get offended. They get angry with you. Then you remain silent, but it does smell.”

“Personally it would be good to have those rules. Putting myself in the position of those that smoke, I know it would be hard. I know because of what I went through with my grandma and my dad. They smoked. It’s very hard to stop. My dad got angry and frustrated when he tried to stop. It was hard. He couldn’t. It’s easy to ban smoking, but putting yourself in the place of someone else, it’s hard for

me to say.”

“I think it's a win-win situation. Someone who's a smoker should be motivated enough to quit smoking rather than lose their apartment. They benefit, and the people around them benefit.”

Most participants in both groups reported that having an area where people can smoke is useful. Some participants expressed concern about designated smoking areas because they might still smell the smoke, even if the smoking area was in the parking lot. The participants suggested solutions such as creating a smoking area far away from the complex or having a closed room only for smokers. Facilitators and Barriers in Establishing Smoke-free Housing When the participants were asked about their willingness to advocate for smoking rules in their apartment complex, many participants said they would support the rules. Ways they would help to create or enforce the rules include talking to apartment owners, holding owners accountable for enforcement, knocking on doors and sharing the rules with tenants, and asking Health Services for assistance. When participants were asked what might prevent them from working towards having smoking rules for their apartment complex, both groups reported that smokers’ reactions could be a barrier. The English-


language participants cited tobacco companies as a barrier. The Spanish-language participants reported that apartment owners could also be a barrier as well as language:

“I almost don’t talk much with the apartment manager because I don’t speak English. She would be responsible for establishing smoking rules.”

The participants were asked about the support or resources they would need to ask for a smoking rule in their apartment complex. They said that any information would be helpful, such as pamphlets that describe the consequences of smoking and secondhand smoke and informational videos like the ones seen in waiting rooms such as WIC or dentists’ offices. A participant commented on finding a common ground:

“California has the best laws in the U.S. There are many laws in place and we need to know our rights. We also need to know the smoker’s rights and what they can and can’t do as well. The

people who smoke have rights too and we need to understand how to live together.” When participants were asked for their opinion about which organizations or individuals could help support them in this effort, they suggested the public health department, American Cancer Society, environmental groups, smoking cessation groups, apartment owners and managers, legislators, elected officials, school directors, and neighbors. One participant stressed the importance of working closely with the police department for enforcement:

“The other option would be the police department. They should write them tickets. Like not using a

seatbelt, things like that.” Strategies for Engaging Multi-Unit Housing Residents to Promote Smoke-free Environments Participants were asked to describe strategies to engage residents of multi-unit housing to promote smoke-free living. Some participants were in agreement that promoting smoke-free environments could be a lengthy process, since apartment complexes typically gives a 30 - 60 day warning before new regulations are implemented. They voiced frustration with this wait period since their families will continue to be exposed to smoke during this time. Participants said that smokers need to understand the needs of non-smokers and emphasized the need for having discussions with the manager, residents, and owners. They also felt that the managers need to be on board and be willing to enforce smoking rules, and that enforcement should not be left to the residents. A Spanish-language participant talked about the existence of tobacco prevention resources and cited a California campaign with the slogan, “Your right to smoke ends when my right to breathe begins.” He also said people need to understand the law and their rights and fight for them. FINDINGS FROM SMOKE-FREE MULTIUNIT HOUSING – CURRENT SMOKERS’ PERCEPTIONS One focus group in English and 3 interviews in Spanish were conducted in April 2013 with adults who live in multiunit housing and who currently smoke.


Perceptions of Secondhand and Thirdhand Smoke on Health and Level of Concern Participants were asked for their opinion about secondhand and thirdhand smoke and its effect on health. Overall, a majority of the participants reported that secondhand smoke was unhealthy and more damaging than smoking. None of the participants knew about thirdhand smoke; one had guessed that it could be when a pregnant woman smokes and she exposes her developing child. Most participants were particularly concerned about smoking in the presence of children; some reported not smoking in front of their children. A participant talked about his strong feelings around smoking and children:

“I’ve actually gotten in trouble a couple of times at work because I rip people out of their cars because they’re smoking with a toddler or an infant in the car.”

When participants were asked about the ways exposure to secondhand or thirdhand smoke might affect others, the participants said that it not only bothers people with its overwhelming smell, but also causes diseases such as lung disease, cancer, asthma, and emphysema. Some participants also reported the fact that apartment walls turn brown and smoke travels through the vents. The participants were asked how much of a problem being exposed to secondhand or thirdhand smoke was for them, other people, or children. The Spanish-language participants considered it to be a big problem, especially for kids, while one English-language participant said it was not a problem because he smokes 20 feet from the house. Experience in Being Asked Not to Smoke When participants were asked how they felt when asked not to smoke, there were mixed responses. One participant talked about his experience:

My daughter has asked and I’ve tried to quit. It makes me feel bad, I know it bothers her. And I see her watching me smoke and I promise her I’m going to try and quit.

Several participants reported never being asked to stop smoking in their home. Perceptions on Smoking Rules and Regulations for Multiunit Housing The participants were asked for their opinion about regulations for apartment complexes that only allowed smoking in the apartments or specific smoking areas or rules that don’t allow smoking in apartments, patios, or anywhere on the grounds. Overall, participants were not opposed to smoking rules and regulations. An English-language participant talked about smoking and housing rules:

”If you’re a smoker and you want to move into some place, make sure you don’t try to move into a place that has those rules and you find one that accommodates to your lifestyle. If it doesn’t work for

you, then find somewhere else.” In both groups, some of the participants thought there should be designated areas for smoking while others thought that smoke should not be allow at all in the complex:

“It would be good to have a rule where you couldn’t smoke anywhere, inside, outside or in the apartment. Because the smoke comes in from the parking lot, etc. no matter where you smoke. I

would smoke less if there was a rule.”


An English-language participant voiced her opposition to smoke-free apartments:

“It would bug me if I’m paying rent for me to have to go off the property to go smoke, like go around the corner when it’s pouring rain. I should be able to go in my backyard and smoke a cigarette and

not have to worry about breaking rules or laws.” Another participant supported this opinion:

“It takes about, what, five minutes to smoke a cigarette. That’s your five minute break to get away from the kids.”

Although several participants reported that they smoke in their apartments, when prompted with the question about a rule that will allow them to smoke in their apartment and nowhere else, almost all participants were against this rule and reported kids’ health as a priority:

“I would not even live there because it’s affecting my kids. My kids don’t have that choice to get away from it. If I’m in my house and they’re in my house, they get affected, too.”

Another participant talked about their right to smoke:

“Everyone should have their own choice, if you want to smoke at the apartment we should be allowed to do that.”

Facilitators and Barriers in Establishing Smoke-free Housing When the participants were asked how a smoke-free multiunit housing regulation would affect them, the responses varied. Some participants said it would be difficult for stay-at-home moms or the elderly, since they are not as mobile. A few participants said they preferred the regulation, and a few participants reported that they would find an alternative to smoking cigarettes such as electric cigarettes or chewing tobacco. There were also mixed responses regarding whether participants would choose to move into an apartment with rules when looking for a place to live. A female participant said:

“I’m not ready to quit. When I’m ready to quit, maybe I’ll move into a place like that.” Participants expressed concerns particularly for senior citizens and children:

“I think that nobody should be allowed to smoke with kids in the house or in the car.” When talking about enforcement and government involvement, a participant added:

“It should be none of their business. When it comes to actually affecting children, I think that's where

they need to step in because…they don't have a choice.”


Strategies for Engaging Multi-Unit Housing Residents to Promote Smoke-free Environments When participants were asked whether they would support a smoke-free rule, all of the Spanish-language participants said that they would work to support it. The English-language participants said they would support it only if there was a designated area to smoke. English-language participants emphasized the need for more information about thirdhand smoke and its consequences, and felt it should be brought to people’s attention:

“I actually think thirdhand smoke is something that the county wants to work on to increase

awareness of it and maybe do some campaigns about it.”

SUMMARY OF THE SMOKE-FREE MULTIUNIT HOUSING FOCUS GROUPS Both the smokers’ and non-smokers’ groups had at least a few participants who supported having a smoke-free living environment. Most participants, with the exception of one in the smokers’ group, thought smoking was a big problem, and they were all aware of the consequences and health problems associated with smoking. While many participants were aware of the health consequences of secondhand smoke, not everyone knew about thirdhand smoke. Non-smoking English-language participants were more knowledgeable about thirdhand smoke than the Spanish-language participants. The smokers were not as aware of thirdhand smoke as non-smokers. All focus groups had participants who supported smoking rules for multiunit housing. There were differences in the type of rule that people preferred. The non-smoking participants supported both completely smoke-free complexes as well as designated smoking areas, with many expressing the importance of reducing children’s exposure to smoke. Participants in the same group reported the need for enforcement, and some reported that enforcement should come from the apartment complex management or owners. All non-smokers and Spanish-language smokers were willing to make efforts to have smoke-free rules in their apartment complex. While English-speakers smokers would support an effort to have a rule, they were more hesitant and expressed that smoking should still be allowed in some places. Regarding barriers to establishing smoke-free housing, the participants discussed lack of information and the Spanish-language participants reported language as a barrier. A few participants in both groups also reported that the owner or manager could be a barrier to success if they are not on board. Finally, the smokers expressed the need for more materials about thirdhand smoke and its health consequences.

Documents

Unhealthy Advertisements on Corner Storefronts and Smoke ...A semi-structured focus group questioning guide was developed by the evaluation team and staff from the Stanislaus County